Testing the Context Responsivity Hypothesis: Managing Resistance in Cognitive Behavioural Therapy

Despite growing recognition of the importance of context-responsivity in psychotherapy, and recommendations to develop context-responsive models through identification of clinical markers to which therapists need to be responsive, the notion of context-responsivity in relation to key markers such as resistance remains largely understudied. The current study sought to examine therapist responsiveness during identified moments of resistance (i.e., client disagreement with therapist direction) in the context of cognitive-behavioural therapy (CBT) for generalized anxiety disorder (Westra et al., 2015). There were two ways in which context-responsivity was investigated. The first was to examine whether differences in therapist style (i.e., more supportive and less directive behaviour) in the presence of disagreement go on to predict proximal (i.e., level of subsequent resistance in the session following therapist management of resistance) and distal (i.e., pre-to-post worry reduction) therapy outcomes. To this end, the present study utilized the Manual for Rating Interpersonal Resistance (Westra et al., 2009) to identify moments of client disagreement with therapist direction. In turn, the Motivational Interviewing Treatment Integrity (MITI; Moyers et al., 2010) was used to rate therapist use of theoretically indicated motivational interviewing (MI) skills (e.g., level of empathy, collaboration, evocation, and support of client autonomy) during identified moments of disagreement. The second approach to investigating context-responsivity was through comparing variations in therapist MI adherence in the presence of disagreement, with variations in therapist general MI adherence during randomly selected moments in therapy, in order to examine whether the timing of therapist use of MI principles differentially impacts treatment outcomes. Results indicated that clients whose therapists displayed higher levels of MI relational conditions in the context of disagreement had substantially lower levels of subsequent resistance and post-treatment worry. Furthermore, while variations in therapist MI adherence in the context of disagreement were consistently and substantially related to CBT outcomes, variations in therapist general MI adherence were not. These findings provide support for the context-responsivity hypothesis, and serve to suggest that systematic incorporation of the client-centered relational conditions advanced in MI to the responsive management of resistance in CBT is a valuable clinical endeavor which should become a priority for clinical training.